Systems, methods, and platforms for automated quality management and identification of errors, omissions and/or deviations in coordinating services and/or payments responsive to requests for coverage under a policy

ABSTRACT

In an illustrative embodiment, systems and methods for monitoring insurance claims include identifying, based on predetermined monitoring frequency, insurance claims identified for vulnerability detection processing. Vulnerability detection features may be extracted from data files of the claims, which provide an indication of claim handling deficiencies that can cause claim leakage. A trained vulnerability detection data model can be used to detect claim handling vulnerabilities within the extracted vulnerability detection features where each of the vulnerabilities may include a likelihood of the vulnerability resulting in claim leakage. The vulnerability detection data model may be trained with a data set customized to a respective insurance provider for each claim. Vulnerability scores indicating an overall likelihood of claim leakage can be calculated for the claims based on the detected claim handling vulnerabilities. Vulnerability scores for claims assigned to a user may be presented within a user interface screen at a remote computing device.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims priority to U.S. Provisional Patent ApplicationSer. No. 62/785,539 entitled “Systems, Methods, and Platforms forAutomated Quality Management and Identification of Errors, Omissionsand/or Deviations in Coordinating Services and/or Payments Responsive toRequests for Coverage Under a Policy” filed Dec. 27, 2018, which ishereby incorporated by reference in its entirety.

SUMMARY OF ILLUSTRATIVE EMBODIMENTS

The forgoing general description of the illustrative implementations andthe following detailed description thereof are merely exemplary aspectsof the teachings of this disclosure and are not restrictive.

In some embodiments, systems and methods for monitoring insurance claimsinclude identifying, based on predetermined monitoring frequency,insurance claims due for vulnerability detection processing.Vulnerability detection features may be extracted from data files of theclaims, which provide an indication of claim handling deficiencies thatcan cause claim leakage. A trained vulnerability detection data modelcan be used to detect claim handling vulnerabilities within theextracted vulnerability detection features where each of thevulnerabilities may include a likelihood of the vulnerability resultingin claim leakage. The vulnerability detection data model may be trainedwith a data set customized to a respective insurance provider for eachclaim. Vulnerability scores indicating an overall likelihood of claimleakage can be calculated for the claims based on the detected claimhandling vulnerabilities. Vulnerability scores for claims assigned to auser may be presented within a user interface screen at a remotecomputing device.

In some embodiments, the claims monitoring system may include a feedbackmechanism that allows provides automatic oversight for trackingresolutions to identified vulnerabilities within claims and generatingperformance information for claims handlers that can be used bysupervisors. In some embodiments, the feedback mechanism may increase afrequency of vulnerability detection processing of open claims that havebeen identified as having a high risk for leakage due to previouslydetected vulnerabilities. In some examples, claims that as having a highrisk for leakage are processed and evaluated for vulnerabilities morefrequently than claims that have a medium or low risk of leakage.

BRIEF DESCRIPTION OF THE DRAWINGS

The accompanying drawings, which are incorporated in and constitute apart of the specification, illustrate one or more embodiments and,together with the description, explain these embodiments. Theaccompanying drawings have not necessarily been drawn to scale. Anyvalues dimensions illustrated in the accompanying graphs and figures arefor illustration purposes only and may or may not represent actual orpreferred values or dimensions. Where applicable, some or all featuresmay not be illustrated to assist in the description of underlyingfeatures. In the drawings:

FIG. 1 is a block diagram of an example environment for a claimsmonitoring system;

FIG. 2A is a block diagram of a work flow for generating a dataanalytics model for monitoring claim quality;

FIG. 2B is a block diagram of a work flow for identifying targetvariables from loss data and claim loss data associated with sets offeatures for training vulnerability detection data models;

FIG. 3 is a table of targeted claim features for a claim monitoringsystem;

FIG. 4 is a table of vulnerability metric categories for detectingvulnerabilities associated with claim leakage;

FIGS. 5A-5C illustrate user interface screens for providing detectedclaim vulnerability information to an insurance provider;

FIGS. 6-12 illustrate user interface screens for providing detectedclaim vulnerability information to an insurance provider;

FIG. 13A is a flow chart of an example method for generating a trainedvulnerability detection data model;

FIG. 13B is a flow chart of an example method for identifying targetvariables for training a vulnerability detection data model;

FIG. 14 is a flow chart of an example method for detectingvulnerabilities within insurance claims;

FIG. 15 is a flow chart of an example method for processing claimvulnerability feedback to an insurance provider;

FIG. 16 is a block diagram of an example computing system; and

FIG. 17 is a block diagram of an example distributing computingenvironment including a cloud computing environment.

DETAILED DESCRIPTION OF ILLUSTRATIVE EMBODIMENTS

The description set forth below in connection with the appended drawingsis intended to be a description of various, illustrative embodiments ofthe disclosed subject matter. Specific features and functionalities aredescribed in connection with each illustrative embodiment; however, itwill be apparent to those skilled in the art that the disclosedembodiments may be practiced without each of those specific features andfunctionalities.

Reference throughout the specification to “one embodiment” or “anembodiment” means that a particular feature, structure, orcharacteristic described in connection with an embodiment is included inat least one embodiment of the subject matter disclosed. Thus, theappearance of the phrases “in one embodiment” or “in an embodiment” invarious places throughout the specification is not necessarily referringto the same embodiment. Further, the particular features, structures orcharacteristics may be combined in any suitable manner in one or moreembodiments. Further, it is intended that embodiments of the disclosedsubject matter cover modifications and variations thereof.

It must be noted that, as used in the specification and the appendedclaims, the singular forms “a,” “an,” and “the” include plural referentsunless the context expressly dictates otherwise. That is, unlessexpressly specified otherwise, as used herein the words “a,” “an,”“the,” and the like carry the meaning of “one or more.” Additionally, itis to be understood that terms such as “left,” “right,” “top,” “bottom,”“front,” “rear,” “side,” “height,” “length,” “width,” “upper,” “lower,”“interior,” “exterior,” “inner,” “outer,” and the like that may be usedherein merely describe points of reference and do not necessarily limitembodiments of the present disclosure to any particular orientation orconfiguration. Furthermore, terms such as “first,” “second,” “third,”etc., merely identify one of a number of portions, components, steps,operations, functions, and/or points of reference as disclosed herein,and likewise do not necessarily limit embodiments of the presentdisclosure to any particular configuration or orientation.

Furthermore, the terms “approximately,” “about,” “proximate,” “minorvariation,” and similar terms generally refer to ranges that include theidentified value within a margin of 20%, 10% or preferably 5% in certainembodiments, and any values therebetween.

All of the functionalities described in connection with one embodimentare intended to be applicable to the additional embodiments describedbelow except where expressly stated or where the feature or function isincompatible with the additional embodiments. For example, where a givenfeature or function is expressly described in connection with oneembodiment but not expressly mentioned in connection with an alternativeembodiment, it should be understood that the inventors intend that thatfeature or function may be deployed, utilized or implemented inconnection with the alternative embodiment unless the feature orfunction is incompatible with the alternative embodiment.

Insurance providers employ quality assurance managers and front-linemanagers to monitor how insurance claims are handled within theirorganizations to reduce the amount of claim leakage (money that is lostdue to claims management inefficiencies caused by failures to followexisting policies and procedures related to claims handling) thatoccurs. However, each of these managers often have hundreds or thousandsof claims under their supervision, which makes it impossible to conductthorough reviews of all open claims. Therefore, managers only reviewsmall samples of open claims, making providers vulnerable to leakagefrom unreviewed claims. Further, the managers performing manual reviewsrely on their intuition to detect vulnerabilities and deficiencieswithin the claims, which may not be an accurate reflection of the truecauses of claim leakage. Additionally, performing audits of closedinsurance claims is both labor and time intensive (about 6-8 weeks). Asa result, closed claim file audits are conducted infrequently, whichdelays the value that can be created through the lessons learned for howto identify root causes of leakage and mishandling of claims.

Aspects of the present disclosure are directed to computing systems andmethods for monitoring insurance claims to identify vulnerabilities thatcan cause inefficiencies with the claims handling process. In someimplementations, claims handling personnel for an insurance carrierinteract with a computing system to provide documentation associatedwith an insurance claim, which can include both structured andunstructured data. For example, the structured data can include datainput directly to the system that can be organized and stored in arelational database (e.g., insurance policy information, dates and timesof when a claimant was contacted, official medical diagnoses).Unstructured data can include any information from complex data sourcesthat are stored in multiple formats (e.g., notes regarding any calls orinteractions with a claimant, medical professional, law enforcementprofessional, or vehicle inspector, receipts, police reports, medicalrecords, automobile inspection reports for automobile insurance claims).Because the claims monitoring system can extract targeted features fromboth the structured and unstructured claim data by efficiently locatingand extracting the targeted features from data sources in multipleformats, the system's ability to identify claim leakage is significantlyimproved because the data is not just limited to structured data.

Based on the information provided, in some examples, the claimsmonitoring system can process the documentation and data for open claimsto identify weaknesses or vulnerabilities in the claims handling processthat can lead to claim leakage, which is an amount of money that is lostdue to claims management inefficiencies caused by failures to followexisting policies and procedures related to claims handling. In someexamples, the money lost from claims management inefficiencies manifestsas litigation costs that could have been mitigated if the proper claimshandling processes had been followed or as loss of clients due to poorclaims handling services. Examples of vulnerability issues that can leadto claim leakage are failing to call a party to a claim within a timelyfashion, failing to identify possible coverage issues, failing to refera claim to counsel at an appropriate time, and failing to obtainappropriate documentation for the claim. In some examples, the claimsmonitoring system may also process closed claims to identifyvulnerabilities within the closed claims that can be used by thecomputing system to adaptively learn which characteristics of claimslead to negative outcomes that cause leakage.

The claims monitoring system, in some implementations, trains a machinelearning data model to identify claim vulnerabilities using one or moredata sets that have been customized to the client's own businesspractices and claims handling interactions with customers. In someexamples, the system processes closed claims for the client to extractfeatures related to how the client processes claims to generate a clientdata set. The client data set, in one example, is normalized and mergedwith a historical data from multiple data sources to produce acustomized data set for the client. In some examples, the system trainsthe data model with the merged data set for a particular client and atargeted set of weighted training variables related to proactivelyidentifying claims vulnerabilities. In some examples, the trainingvariables are weighted based on a relative importance of each of thevariables to identifying a particular type of claim leakage.

The system, in some embodiments, identifies vulnerabilities for a set ofopen claims by applying the trained data model to extracted features ofthe open claims. In some implementations, the trained data modelprovides the system with learned machine knowledge about how to extractvaluable features from the unstructured data in the insurance claims.For example, based on the trained model, the claims monitoring systemcan identify key phrases used by claims handlers, medical professionals,law enforcement officers, vehicle inspectors, and others providingclaims documentation that can be used to identify features of the claimsrelated to potential vulnerabilities based on how they are used relativeto the key features. The claims monitoring system, in some examples, canuse the trained data model to predict, based on the identified featuresof the open claim, a likelihood that one or more vulnerability issueshas occurred. The system may also score each open claim based on itslikelihood of leakage occurring. In some embodiments, the system issuesnotifications to claims handling supervisors when vulnerabilities areidentified so that the claims handlers can rectify any of the identifiedvulnerabilities before claim leakage occurs.

In some implementations, the claims monitoring system can also include aclosed feedback loop that performs in-process validation of resolutionsof identified claim vulnerabilities. For example, the system mayincrease a frequency of vulnerability detection processing of openclaims that have been identified as having a high risk for leakage dueto previously detected vulnerabilities. In other examples, the systemmay rank or score the performance of each claims handler for aninsurance carrier based on a number or percentage of claimvulnerabilities that are detected within a claim or set of claimsassigned to a respective claims handler. In some examples, each claimshandler may be ranked relative to other claims handlers associated withan insurance carrier or relative to claims handlers with a similaramount of experience or seniority within the organization. The claimsmonitoring system, in some examples, may increase the frequency ofprocessing claims assigned to a claims handler whose performance, asevidenced by the performance score or ranking, is below that of theother claims handlers in the organization or below that of other claimshandlers with similar experience.

The implementations of the present disclosure provided herein are asignificant improvement over manual, conventional methods of claimsmonitoring and are necessarily rooted in computer technology.Conventional claims monitoring systems rely upon manual file reviews byquality assurance and front-line managers. Because each of thesemanagers often have hundreds or thousands of claims under theirsupervision, it is impossible for them to conduct thorough reviews ofall open claims. Therefore, managers only review small samples of openclaims, making providers vulnerable to leakage from unreviewed claims.Further, the managers performing manual reviews rely on their intuitionto detect vulnerabilities and deficiencies within the claims, which maynot be an accurate reflection of the true causes of claim leakage. Theimplementations of the present disclosure provide a technical solutionto the technical problem by providing a significant improvement of themanual review methods in that the systems and methods of the presentdisclosure can perform real-time reviews of all open claims for aprovider on a periodic basis throughout the life of a claim. Further,because the system detects claim vulnerabilities using a trainedvulnerability detection data model that is customized to individualinsurance providers, claims are processed using standardized, calibratedvulnerability detection metrics rather than with inconsistencies,subjectivity, and blind spots in human intuition.

Because performing audits of closed insurance claims is both labor andtime intensive, closed claim file audits are conducted infrequently,which delays the value that can be created through the lessons learnedfor how to identify root causes of leakage and mishandling of claims.The present disclosure provides a technical solution to a technicalproblem rooted in computer technology by extracting targetedvulnerability detection features within unstructured claim data filesidentified by machine learning algorithms. By continuously (e.g., daily,weekly, monthly, or whenever newly closed claims are identified)updating the data sets that are used to train the vulnerabilitydetection data models for providers, the claims monitoring system cancontinuously leverage learned knowledge from closed insurance claims toidentify vulnerabilities within open insurance claims.

FIG. 1 is a diagram of an example environment 100 for a claimsmonitoring system 108. The diagram illustrates relationships,interactions, computing devices, processing modules, and storageentities used to gather, generate, organize, store, and distribute theinformation necessary to proactively detect potential issues with howinsurance claims are handled, referred to as vulnerabilities, andprovide recommendations for how to resolve the issues to prevent orreduce claim leakage. In some implementations, the vulnerabilitydetection and resolution information can be used by claims managers 102a and handlers 102 b for insurance providers (together, insuranceproviders 102) to effectively assess performance of claims handlers andprovide training to the claims handlers through a feedback mechanism ofthe system 108 that increases a monitoring frequency of claims withdetected vulnerabilities to determine whether root causes ofvulnerabilities have been resolved.

In certain embodiments, insurance providers 102 may connect to theclaims monitoring system 108 via a number of computing devicesdistributed across a large network that may be national or internationalin scope. The network of insurance providers 102 can be separate andindependent from networks associated with other entities in the claimsmonitoring environment 100, such as the external entities 104. Inaddition, the data handled and stored by the insurance providers 102 maybe in a different format than the data handled and stored by the otherentities of the loss determination environment 100. The insuranceproviders 102 may include, in some examples, brokers,insurance/reinsurance carriers, or any other person interacting with theclaims monitoring system 108 by performing actions related to claimshandling and monitoring. For example, the providers 102 can includeinsurance carrier employees 102 a who ensure proper claims handling fromthe time an insurance claim is reported until a final claim decision andcorresponding payment is made and managers 102 b for the insurancecarriers who supervise the performance of claims handlers 102 a.

In some examples, the claims handling personnel 102 a, via one or moredistributed computing devices, interact with the various parties to aninsurance claim (e.g., for an automobile accident, law enforcementofficers, medical professionals, each driver or person riding in the carthat was damaged, vehicle inspectors) and provide inputs to the system108 associated with those interactions. Any data associated with a givenclaim is stored in data repository 110 as claim data 112, which caninclude both structured and unstructured data. In some examples, theclaim data 112 may include data for both open and closed claims. In someimplementations, the claims handlers 102 a may directly input data tothe system 108 that is organized into relational databases and stored asstructured data (e.g., insurance policy information, claimidentification codes, dates and times of when a claimant was contacted,official medical diagnoses). The claims handlers 102 a may also provideto the system 108 other documents related to a claim that are stored indata repository 110 as unstructured data in multiple formats. In someexamples, the claims handlers 102 a may provide the documents to thesystem by scanning, uploading, or downloading from a data source the(e.g., receipts, police reports, medical records, automobile inspectionreports for automobile insurance claims). The unstructured data may alsoinclude free text notes claims handlers input directly to the system(e.g., notes regarding any calls or interactions with a claimant,medical professional, law enforcement professional, or vehicleinspector). In one example, the claim data 112 for a respective claimportfolio includes a combination of document files and data tableentries associated with the respective claim. Additionally, the system108 may store claim data 112 for each insurance provider 102 in the datarepository 110.

The insurance providers 102, in some embodiments, may also includeclaims handling managers 102 b for insurance carriers who supervise theperformance of groups of claim handlers within the insurance carrierorganization. In some implementations, the claims monitoring system 108can provide the claims handling managers 102 b with informationregarding the performance of the claims handlers 102 a under his or herreview and any detected vulnerabilities within any claims under themanger's purview. The system 108, in some examples, provides the claimhandling information to the managers 102 b within a dashboard interfacescreen that a manager can access by providing log in credentials at theinterface screen.

Upon receiving manager login credentials, the system 108 provides adashboard interface screen to the associated computing device with asummary view of each of the claims assigned to a claims handler 102 aunder the supervision of the manager 102 b (See FIGS. 5A-5C). In someexamples, the summary view within the dashboard interface screendisplays a priority for review (display field 504 in FIG. 5A) thatcorresponds to a likelihood that one or more of the vulnerabilitiesdetected within a respective claim will result in leakage. For example,claims with a high review priority detected vulnerabilities that have ahigher likelihood of resulting in leakage or a higher cost associatedwith the leakage than claims with a review priority of “low” or “ontrack.” The claims monitoring system 108 also provides the managers 102b an opportunity to view and drill down on details of the claimvulnerabilities, which may include each type of vulnerability detectedby the system 108, issues associated with the vulnerabilities couldresult in claim leakage, a likelihood of occurrence of the issue basedon the detected vulnerability, and one or more potential root causes ofthe issue (see FIG. 10). In some examples, the managers 102 b caninteract with the user interface screens presented by the system 108 toprovide information regarding issue resolution of the detectedvulnerabilities or to flag one or more detected vulnerabilities forfollow up at a later date.

External entities 104, in some implementations, include a number ofcomputing devices distributed across a large network that may benational or international in scope. The network of external entities canbe separate and independent from networks associated with other entitiesin the loss determination environment 100, such as the insuranceproviders 102. In addition, the data handled and stored by the externalentities 104 may be in a different format than the data handled andstored by the other participants of in the claims monitoring environment100. The external entities 104 can include any type of external systemthat interfaces with the claims monitoring system 108 to provide datarelated to processing claims such as medical facility computing systems,law enforcement computing systems, and inspector computing systems. Insome examples, the external entities 104 can directly upload claimdocumentation to the system 108 without intervention of a claims handler102 a. For example, medical personnel can upload or transmit medicalrecords of patients involved in an open claim 108 to the claimsmonitoring system 108 and associated with the appropriate claim withinclaim data 112.

In some examples, the external entities 104 may also include computingsystems of other claims monitoring systems, governments, ororganizations that provide historical data related to insurance claimsand any leakage that resulted from how the claims were handled. In someimplementations, the system claims monitoring 108 stores the datareceived from the external entities 104 along with data gathered fromthe insurance providers 102 interacting with the system 108 ashistorical data 116 in data repository 110. In some embodiments, theclaims monitoring system 108 trains a machine learning data model usedto detect vulnerabilities within claims with a combination of thehistorical data 116 and provider-specific production data, which isreferred to as merged data 118.

In some embodiments, the claims monitoring system 108 may include one ormore engines or processing modules 130, 132, 134, 136, 138, 140, 142,146 that perform processes associated with monitoring open insuranceclaims for vulnerabilities that can lead to claim leakage andpotentially preventable costs for insurance providers 102. In someexamples, the processes performed by the engines of the claimsmonitoring system 108 can be executed in real-time to provide animmediate response to a system input such as a request by a claimshandling manager 102 b to view a status of all open claim being handledby a claims handler 102 a under the supervision of the manager 102 a. Inaddition, the processes can also be performed automatically in responseto a process trigger that can include a specific day or time-of-day orthe reception of data from a data provider (e.g., one of the externalentities 104 such as a medical provider or law enforcement officer), oneof the claims handlers 102 a, one of the managers 102 b, or anotherprocessing engine.

In some implementations, the claims monitoring system 108 may include auser management engine 130 that may include one or more processesassociated with providing an interface to interact with one or moreusers (e.g., individuals employed by or otherwise associated withinsurance providers 102 such as the claims handlers 102 a and managers102 b) within the claims monitoring environment 100. For example, theuser management engine 130 can control connection and access to theclaims monitoring system 108 by the insurance providers 102 viaauthentication interfaces at one or more external devices 158 of theinsurance providers 102. In some examples, the external devices 170 mayinclude, but are not limited to, personal computers, laptop/notebookcomputers, tablet computers, and smartphones. In some implementations,the user management engine 130 controls which system data is displayedto which system user. For example, the user management engine 130associates each claims handler 102 a and manager 102 b with a set ofopen and/or closed insurance claims and only information associated withthe set of claims and/or other authorized information is displayed forviewing and editing by a particular user based on receivedauthentication credentials.

The claims monitoring system 108, in some implementations, includes aclaim processing engine 146 that extracts key vulnerability detectionfeatures from stored claim data 112 for each insurance claim, both openand closed, monitored by the system 108. When processing unstructureddata from an insurance claim, (e.g., notes regarding any calls orinteractions with a claimant, medical professional, law enforcementprofessional, or vehicle inspector, receipts, police reports, medicalrecords, automobile inspection reports for automobile insurance claims),the claim processing engine 146 may apply a natural text detectionalgorithm to the unstructured data file to extract textual features ofthe file. In some examples, the claim processing engine 146 uses learnedmachine knowledge to determine which of the features of both thestructured and unstructured data in the claim are applicable to claimvulnerability detection. For example, the learned machine knowledge mayinclude specific phrases used by claims handlers, medical professionals,law enforcement officers, vehicle inspectors, and others providingclaims documentation in the context of an automobile insurance claimthat can be used to identify features of the claims related to potentialvulnerabilities based on how they are used relative to the key features.

In some implementations, the claim processing engine 146 extracts keyvulnerability detection features from closed insurance claims, referredto as client production data 129. The vulnerability detection features,in one example, may be specific to individual insurance providers 102based upon a respective provider's business rules and claims handlingprocesses. In addition to one or more default features, the analyticstraining engine 134, using machine learning algorithms, can learnadditional provider-specific vulnerability detection features over timebased on shared characteristics between claims for a particular provider102. In other examples, providers 102 may directly provide theirbusiness rules and claim handling characteristics to the claims handlingsystem 108. In some examples, analytics training engine 134 uses theclient production data 129, in combination with historical data 116, totrain a machine learning data model to detect vulnerabilities withinopen claims that are likely to cause claim leakage.

The claim processing engine 146, in some embodiments, also extracts keyvulnerability detection features from open insurance claims, which areused by vulnerability detection engine 138 to identify leakagevulnerabilities within the open claims. In one example, the claimprocessing engine 146 organizes the key vulnerability features extractedfrom each open insurance claim into feature vectors, which are stored indata repository 110 as claim feature vectors 114. Vulnerabilitydetection engine 138, in some embodiments, identifies vulnerabilitiesfor a set of open claims by applying a data model trained to theextracted features of the open claim feature vectors 114. In someimplementations, the vulnerability detection features can include anyinformation associated with one or more vulnerability metrics (see FIG.4). For example, vulnerability detection features can include dates ofcontact with each of the parties associated with an insurance claim,dates of missed calls from each of the parties, excerpts (e.g., keywords, phrases, sentences) from summaries of conversations with each ofthe parties, coverage information for an insurance policy, informationregarding referrals to management or counsel, investigative action planinformation, summaries of statements of each of the parties, lossinformation, and liability analysis information.

The claims monitoring system 108, in some examples, may also include adata management engine 132 that organizes, stores, and controls accessto data in data repository 110. For example, in response to receiving anupload of a document associated with an insurance claim, the datamanagement engine 132 links the document with a particular claim basedon common identification characteristics (e.g., claim number, claimreporting date, incident date, names and/or birth dates of affectedparties) and stores the linked document as claim data 112. Further, uponreceiving any updates from claims handlers 102 a or managers 102 bregarding the resolution of a detected vulnerability, the usermanagement engine 132 updates the claim data 112.

In some implementations, the data management engine 132 also generatesmerged data sets from historical data 116 and client production data129. In some examples, the data management engine 132 normalizes theclient production data 129 generated by the claim processing engine 146for the respective provider 102 to be compatible with the historicaldata 116 and merges the normalized client production data 129 historicaldata 116 into a single merged data set 118 that is customized torespective provider 102.

For example, FIG. 3 illustrates a table 300 of claim features 302 forhistorical data 116, client production data 129, merged data 118, and/orthe claim feature vectors 114 for open insurance claims. The claimfeatures 302 included within the table 300 are not meant to be anexhaustive list but are merely exemplary of features that can be used bythe system 108 to detect vulnerabilities associated with claim leakage.In some implementations, the claim features 302 can include claimidentification information, date the claim was open, assigned claimhandler, type of claim, loss description, loss amounts associated withindemnity, medical, reserve, and salvage, whether legal proceedings havebeen pursued, and supervisor identification code. In addition, the claimfeatures 302 can also include an indicator for whether an externaladjustor is involved in a claim evaluation process, a litigation statusindicator, whether the claim involves salvage items and a total amountfor the salvage items, and whether the claim is qualified forsubrogation. Each claim feature 302 has a corresponding normalizationmethod 304 used by the data management engine 132 to normalize a claimfeature of client production data 129 to be compatible with storedhistorical data 116. For example, the normalization methods 304 mayinclude mapping features to specific values (e.g., Yes/No), convertingfeatures to a float value, removing abbreviations, or converting toanother predetermined format. In some examples, the claim features 302can correspond to either extracted features 226 and/or target variables228 used by analytics training engine 134 to train the vulnerabilitydetection data models as shown in FIG. 2B.

Returning to FIG. 1, the claims monitoring system 108, in someimplementations, also includes an analytics training engine 134 thattrains vulnerability detection data models for each provider 102 thatinteracts with the system 108 using supervised and/or unsupervisedmachine learning algorithms. Because each merged data set 118 iscustomized to an individual provider 102, the analytics training engine134 can generate a trained data model that is also customized to theindividual provider 102. In some examples, the analytics training engine134 trains a vulnerability detection data model for a provider 102 withdata from the corresponding merged data set 118 for that provider 102and a targeted set of weighted training variables 124 related toproactively identifying vulnerabilities within claims that lead to claimleakage. In some examples, the training variables and weights 124 aredefault values that are manually provided to the system 108 and storedin data repository 110. In one example, the analytics training engine134 may automatically update the training weights and variables 124 asthe machine learning knowledge base grows (e.g., as feedback,highlighting, and comments are received from users at UI screens 600 and700 shown in FIGS. 6-7). In some implementations, the training variablescorrespond to the claim features of the merged data sets 118 and claimfeatures vectors 114.

In some embodiments, the analytics training engine 134 initiatestraining of customized vulnerability detection data models for providers102 on a periodic basis to incorporate additional data for claims thathave been closed since a vulnerability detection data model waspreviously trained to ensure that that trained data models can leverageknowledge from all of the closed claims. For example, if the analyticstraining engine 134, by comparing a date associated with a trainedvulnerability model for a provider 102 to claim closing dates for theprovider 102 stored as claim data 112 in data repository 110, determinesthat the trained model does not incorporate the most recent closedclaims data, then a process for training the respective vulnerabilitydetection data model is initiated (see method 1300 in FIG. 13A).

FIG. 2A illustrates a work flow 200 of how the claims monitoring system108 trains the vulnerability detection data models for each provider102. In some implementations, the claim processing engine 146 extractsfeatures from closed insurance claim 204 for a provider 102 that arecombined with historical loss run data 202, which are used by the totrain an overall vulnerability detection data model 212 for eachprovider 102. In some embodiments, the claim processing engine 146includes a loss description feature extractor 206 that extracts features214 from the closed claim data related to quantifiable losscharacteristics of a claim. For example, the loss characteristics mayinclude loss amounts for indemnity, medical, reserve, and total losses,loss types, and a salvage total. The loss description feature extractor206, in some embodiments, can derive a description of the loss from allof the claim notes in the event that a loss description is not providedin the claim documentation. In some implementations, the lossdescription feature extractor 206 that extracts key words from claimdocumentation to generate a loss description for the claim.

In some examples, the data management engine 132 merges the features 214associated with quantifiable loss characteristics identified by the lossdescription feature extractor 206 with the historical loss run data 202to form a first merged data set, which is used by the analytics trainingengine 134 to train a diagnostic data model 210. In someimplementations, the diagnostic data model 210 can be trained to outputa probability of an occurrence of a claim handling violation or othervulnerability in each phase of insurance claim processing. For example,the output of the diagnostic data model 210 represents in aprobabilistic manner the phases of the claim handling process that arelikely to have violations or other vulnerabilities.

In some examples, the claim processing engine 146 also includes a claimnotes feature extractor 208 that uses natural text detection and otherunstructured data processing techniques to extract one or more relevantfeatures 216 from the claim notes (e.g., notes regarding any calls orinteractions with a claimant, medical professional, law enforcementprofessional, or vehicle inspector) and other unstructured dataassociated with a claim (e.g., receipts, police reports, medicalrecords, automobile inspection reports for automobile insurance claims).In some implementations, the claim notes feature extractor 208 extractsfeatures by applying specific sets of rules to the claim notes. Forexample, the claim notes feature extractor 208 may apply a contactdetection rule to detect instances of when a claims handler made contactwith one of the parties to a claim. The claim notes feature extractor208, in some examples, may apply a natural text detection algorithm tothe unstructured data file to extract textual features of the file.

In some examples, the claim processing engine 146 uses learned machineknowledge to determine which of the features of both the structured andunstructured data in the claim are applicable to claim vulnerabilitydetection. For example, the learned machine knowledge may includespecific phrases used by claims handlers, medical professionals, lawenforcement officers, vehicle inspectors, and others providing claimsdocumentation in the context of an automobile insurance claim that canbe used to identify features of the claims related to potentialvulnerabilities based on how they are used relative to the key features.In one example, the features 216 extracted by the claim notes featureextractor 208 can include dates and times of initial and subsequentcontacts with drivers, passengers, or witnesses, key phrases used by aclaims handler in communication with the parties of an insurance claim,investigation and context in which those phrases were used (e.g., in aphone call or email), coverage analysis information, and lost incomedocumentation information.

The features 216 extracted by the claim notes feature extractor 208, insome implementations, are merged with the output 218 of the diagnosticdata model 210 and historical loss run data 202 and are used to trainthe overall vulnerability detection data model 212. In someimplementations, because the extracted claim notes features 216 aremerged with the output of the diagnostic data model 210 improves theoutput of the overall vulnerability detection data model 212 by removingbias from the data received from an individual provider 102 and alsoenlarges the data set used to train the overall vulnerability detectiondata model 212.

FIG. 2B illustrates an example of a workflow 220 for identifying targetvariables from loss data and claim loss data associated with sets offeatures for training the vulnerability detection data models for eachprovider 102. In some examples, supervised learning algorithms like thevulnerability detection data model can use a set of features/predictorsthat are linked to target variables for training the data model. In someexamples, the target variables may correspond to vulnerability metricsidentified by the trained vulnerability detection data models. In someimplementations, difficulties can arise when the data sets the learningalgorithms used to train the vulnerability detection data model do nothave properly enumerated and labeled information regarding the targettraining variables. In some examples, this type of difficulty can arisewhen claim notes data 224 and historical loss run data 222 is extractedfrom both opened and closed claims data because the extracted data isunstructured and unlabeled. In some implementations, the claimsmonitoring system 108 can be configured to use pattern recognitiontechniques to identify patterns in the extracted data to detect targetvariables for accurately training the vulnerability detection datamodel. Additionally, target variables may represent a type ofvulnerability that can be detected or a conclusion that can be drawnfrom a group of extracted claim features.

For example, the vulnerability detection data model of the claimsmonitoring system 108 can be used to detect whether a recorded statement(R/S) is necessary for a particular claimant. If a recorded statement isnecessary based on aspects of the detected features and not present inthe extracted claims data 224, then a vulnerability associated withclaims leakage may be detected. In this example, whether a recordedstatement should be taken can be considered a target variable to beidentified by the model. Therefore, the analytics training engine 134may scan through extracted historical claim data for evidence of whethera recorded statement was taken along with other features associated withdetermining the necessity of obtaining a recorded statement. In thisexample, the learning algorithm that trains the vulnerability detectiondata model can apply data features from historical loss run data,liability analyses, and claimant information (e.g., age, gender, andother demographic information) along with target variable information(e.g., whether or not a recorded statement was taken) to train thevulnerability model. However, because adjusters use natural language intheir claim notes to document whether a recorded statement was taken,the recorded statement target variable information may not be properlyidentified for use by the supervised learning algorithm.

To solve this difficulty, in some implementations, the analyticstraining engine 134 and/or claim processing engine 146 can apply a textscraping or other type of information extraction before the machinelearning step to specifically identify and extract target variables 228and associated feature data 226 within the claims notes data 224 and/orhistorical loss run data 222. In some examples, when detecting andextracting the target variables (228), the analytics training engine 134can be configured to detect whether certain patterns of words appear inthe notes and use this pattern to create the target variables used totrain the vulnerability detection data model. For example, in a set ofclaims notes, if the analytics training engine 134 identifies the phrase“R/S with John Doe,” the engine 134 can apply a “yes” to the targetvariable for the recorded statement training variable. In someembodiments, once the analytics training engine 134 has detected whethertraining variables are present within both structured and unstructureddata in the claims notes data and loss run data, the detected featuresand training variables are linked 230. In some examples, the linkedtarget variables and feature data can be used for training of thevulnerability detection data model 232. This process of identifyingtarget variables within unstructured claims notes data and loss run data228 and linking the extracted target variables to associated features230 that may not always provide explicit variable identificationprovides a technical solution to the technical problem of detecting andgenerating structured target variables from unstructured, naturallanguage claims notes data and historical loss run data that can be usedto train a customized vulnerability detection data model for eachprovider 102. Further, because each set of linked target variables andfeatures are specific to a particular provider, the trainedvulnerability detection data model is further customized to detectingclaim vulnerabilities for each provider 102 even though providers 102may use different notating conventions when inputting claims notes tothe system 108. In some examples, the linked target variables andassociated features correspond to entries in claim feature vectors thatare used to train the vulnerability detection data models for eachprovider 102.

Returning to FIG. 1, in some implementations, the claims monitoringsystem 108 also includes a vulnerability detection engine 138 toidentify, in real-time, issues with how claims are being handled thatwill likely result in claim leakage. Because the analytics trainingengine 134 generates trained data models that are customized to eachprovider, the vulnerability detection engine 138 can, in real-time,detect vulnerabilities related to claim leakage that are particular toan individual provider 102. For example, each provider 102 may haveclaims handling metrics associated with company policies and proceduresthat are particular to an individual provider 102, and the vulnerabilitydetection engine 138 can identify vulnerabilities that reflect thespecific claims handling metrics of the providers 102.

In some examples, the vulnerability detection engine 138 identifiesvulnerabilities for a set of open claims by applying a trainedvulnerability detection data model for a provider 102 to extractedfeatures of the provider's open claims. In some embodiments, based onthe patterns of claims handling deficiencies identified by thevulnerability detection data model, the vulnerability detection engine138 outputs one or more vulnerabilities detected within the claims thatcorrespond to one or more types of vulnerability metrics 121 associatedwith claim leakage. In some examples, the claims monitoring system 108stores a set of vulnerability metrics 121 in data repository 110, whichthe trained vulnerability detection data models use to detectvulnerabilities within the claims.

For example, FIG. 4 is a table 400 showing vulnerability metriccategories 402 and corresponding overall likelihoods of leakage 404 foreach category 402 indicating a relative importance of each vulnerabilitymetric category 402 with respect to predicting claim leakage. In someimplementations, each vulnerability metric category 402 has one or morecorresponding vulnerability metrics that the vulnerability detectionengine 138, by applying the vulnerability detection data model, uses toidentify any claim vulnerabilities. In some embodiments, each of thevulnerability metrics within a category has its own individuallikelihood of leakage indicating the respective metric's relative impacton whether or not leakage occurs for a given claim. For example, the“contact” metric category can have associated vulnerability metrics suchas whether initial contacts with all pertinent parties were timely andproper and whether subsequent contact was made with all applicableparties. Further, the “investigation” metric category can haveassociated vulnerability metrics of whether all elements ofinvestigative action planning were handled properly, whether allnecessary statements were taken, whether the loss facts investigationwas properly completed, whether the non-auto property damageinvestigation was completed properly, whether the special investigationunit (SIU) was notified properly, and whether a proper third-partyinvestigation was completed.

Returning to FIG. 1, by running the feature vector for a particular openclaim through a machine learning algorithm with a customizedvulnerability detection data model, the vulnerability detection engine138 identifies leakage vulnerabilities within the based on whether ornot the open claim meets each of the metrics. In some embodiments, thevulnerability detection engine 138 also computes a likelihood 520 thateach detected vulnerability will result in leakage (e.g., highly likely,likely, or maybe likely) that corresponds to a confidence level for avulnerability prediction made by the trained model. In some examples,the detected vulnerabilities and associated likelihood of leakage foreach claim are stored as vulnerability data 120 in data repository 110.In some examples, each open claim maintained by the claims monitoringsystem 108 is processed by the vulnerability detection engine 138 forvulnerabilities at periodic intervals and/or at predetermined points inthe lifecycle of the claim. In some implementations, the vulnerabilitydetection engine 138 processes claims at the request of a manager 102 band/or as a feedback check as determined by feedback loop engine 140.

The claims monitoring system 108, in some implementations, can alsoinclude a claim scoring engine 142 that computes a score for each openclaim based on the detected vulnerabilities, which is stored as claimscoring data 128 in data repository 110. In some implementations, thescore computed for each claim can be a function of a number ofvulnerabilities detected within each claim and a correspondinglikelihood of leakage (e.g., severity level) associated with thedetected vulnerability. In one example, the score may be an average ofthe likelihoods of leakage for the detected vulnerabilities (e.g.,critical, high, medium, and low likelihoods of claim leakage associatedwith the vulnerability). In other examples, the claim scoring engine 142may increase an overall likelihood of leakage for the claim based on atotal number of detected vulnerabilities. For example, if fivevulnerabilities with a “medium” likelihood of leakage are detected, theclaim scoring engine 142 may assign a score of “high” to the claimbecause a threshold number of detected vulnerabilities has beenexceeded. In other examples, the score for a claim corresponds to ahighest likelihood of leakage for any of the vulnerabilities detectedwithin the claim. For example, if one vulnerability is detected within aclaim with a likelihood of leakage of “high” (e.g., improper utilizationof experts/expert reports) and one vulnerability is detected with alikelihood of leakage of “low” (e.g., claim should not have beenescalated or transferred), then the claim scoring engine 142 assigns anoverall score of “high” to the claim. In other examples, the claimscoring engine calculates the claim score as a percentage or value on ascale (e.g., 0 to 10) in which lower scores indicate a lower probabilityof claim leakage based upon the number and severity of detectedvulnerabilities and higher scores indicate a higher probability of claimleakage.

The claim scoring engine 142, in some embodiments, may generate rankingsfor open claims of a provider 102 based on the computed scores for eachof the claims. In some implementations, the claim scoring engine 142 mayscore the claims relative to all the open claims for the provider 102 ora subset of claims. For example, each open claim may be ranked relativeto other claims being handled by the same claims handler 102 a orrelative to other claims associated with a particular manager 102 b. Inanother example, a set of claims being handled by one claims handler maybe ranked relative to another set of claims being handled by anotherclaims handler. The claims rankings, in some examples, may also bestored as claim scoring data 128 in data repository 110.

In some implementations, the claims monitoring system 108 also includesa feedback loop engine 140 that provides an automatic oversightmechanism for tracking resolutions to identified claim vulnerabilitiesand generating performance information for claims handlers 102 a thatcan be used by managers 102 b to make personnel decisions (e.g.,promotions, terminations) or provide additional training. For example,the feedback loop engine 140 may increase a frequency of vulnerabilitydetection processing of open claims that have been identified as havinga high risk for leakage due to previously detected vulnerabilities. Inone example, claims that as having a high risk for leakage are processedand evaluated for vulnerabilities more frequently than claims that havea medium or low risk of leakage.

In some implementations, the feedback loop engine 140 can adjust thefrequency with which claims are processed and/or adjust a vulnerabilityscore of an open claim based on feedback received from a claims handler102 a and/or manager 102 b at one or more user interface (UI) screens.For example, for each detected vulnerability, the assigned manager 102 bcan provide feedback regarding whether no action is needed for thedetected vulnerability, that action has been already taken to resolvethe issue for the detected vulnerability, or to remind the manager 102 bagain in a predetermined number of days (see data field 608 for UIScreen 600 in FIG. 6). In some examples, the feedback provided bymanagers 102 b and/or claims handlers 102 a at the UI screens can bestored in the data repository 110 as feedback data 126.

In some examples, the feedback loop engine 140 can rank and/or score theperformance of each claims handler 102 a for particular provider basedon a number or percentage of vulnerabilities and correspondinglikelihoods of leakage that are detected within a claim or set of claimsassigned to a respective claims handler 102 a. In some examples, thefeedback loop engine 140 may rank each claims handler 102 a may relativeto other claims handlers 102 a associated with a provider or assigned toa particular manager 102 b. In other examples, the feedback loop engine140 may rank claims handlers 102 a relative to other claims handlers 102a with a similar amount of experience or seniority within theorganization. In some examples, for claims handlers 102 a havingperformance rankings below a predetermined threshold (e.g., within abottom percentage of performance of all claims handlers 102 a for theprovider, claims handlers 102 a who perform worse than other claimshandlers 102 a with similar experience, or claims handlers 102 a whoconsistently have low scoring claims), the feedback loop engine 140 mayautomatically increase the frequency that the claims handled by the lowperforming claims handler 102 a are processed and evaluated forvulnerabilities by the claims monitoring system 108. Information relatedto the rankings and/or scores for claims handlers 102 a can be stored ashandler performance data 127 in data repository 110.

In some implementations, the claims monitoring system 108 may alsoinclude a front-end driver engine 136 that controls dissemination ofdata and interactions with insurance providers 102 through one or moreUI screens and/or messaging formats (e.g., email, text message, ornotification at an application interface). In some embodiments, useraccess to the system 108 is provided through a website or web-hostedapplication. In some examples, the front-end driver engine 136 canoutput information to the external devices 158 in response to queriesreceived from claims handlers 102 a and/or managers 102 b to viewvulnerabilities for one or more open claims, initiate vulnerabilitydetection for a claim, and view performance scores or rankings for anassigned set of claims handlers 102 b. For example, as shown in FIG. 5A,upon providing login credentials, a manager 102 b can view a set ofclaims assigned to the claims handlers under supervision of the manager102 b at a summary UI screen 500 and can view further details regardingvulnerabilities associated with a claim at detail UI screen 536 (FIG.5C).

Additionally, in response to receiving inputs at UI screens, thefront-end output engine 136 may output, in real-time, any informationassociated with the provided input. For example, in response toreceiving a selection to view potential root causes for a detectedvulnerability, the front-end driver engine 136 may present, inreal-time, a root cause UI screen (e.g., root cause UI screen 1000 inFIG. 10) that provides probabilities of occurrence for each of thepotential root causes for the detected vulnerability.

FIGS. 5-12 illustrate UI screens for providing detected claimvulnerability information to an insurance provider 102, which caninclude managers 102 b and/or claims handlers 102 a. As shown in FIG.5A, upon verification of the login credentials by user management engine130, the front-end driver engine 136 presents a summary view UI screen500 that provides a list of open claims assigned to the user, which inone example may be a manager 102 b. In some implementations, the summaryview UI screen 500 may provide one or more sortable and/or filterableclaim detail fields, such as claim number 502, issue priority 504, lineof business 506 (e.g., auto, home), coverage code 508 (e.g., collision,property damage), adjuster/claim handler name 510, supervisor name 512,date claim was opened 514, loss date 516, number of days the claim hasbeen open 518, and risk exposure type 520. The issue priority 504, insome embodiments, corresponds to a highest likelihood of leakage of anyvulnerability detected within the claim (e.g., low, medium, or high). Insome examples, if no vulnerabilities are detected, then the issuepriority field 504 may indicate that the claim is “on track.” In someimplementations, the front-end driver engine 136 can sort and/or filterthe claims according to one or more of the characteristics 502-520 inresponse to a user input.

FIG. 5B shows a claim filtering UI screen 522 that allows system usersto filter the claims presented in the summary UI screen 500 according toone or more criteria at filter input fields 524-534. In someimplementations, the filter criteria input fields can include line ofbusiness 524, adjuster name 526, supervisor name 528, loss date 530,range of days open 532, and issue priority/likelihood of leakage 534.Other filtering criteria can also include reserve, expense, and lossamounts as well as type of exposure.

The UI screen in FIG. 5C shows a claim detail UI screen 536 presented bythe front-end driver engine 136 upon selection of one of the claimspresented within summary view UI screen 500 (FIG. 5A). In some examples,the claim detail UI screen 536 provides detailed information related tothe detected vulnerabilities or issues that could result in claimleakage. For example, the UI screen 536 can include a claim summarysection 538 that includes at least a portion of the informationdisplayed for the claim in the summary view UI screen 500 shown in FIG.5A. In some examples, the claim summary section 538 can include theclaim number, line of business, coverage code, open date, loss date,number of days open, exposure type, feature number, insured name, lossdescription, adjuster name, reserve amount, expense amount, paid loss,and issue priority. In some examples, the claim detail UI screen 536 canalso include an alert section 540 that displays summary information forone or more detected vulnerabilities associated with the claim. In someexamples, the summary information for the detected vulnerability caninclude claim phase associated with the vulnerability 542 (e.g., contactphase), leading practice question associated with the vulnerability 544(e.g., “Were initial contacts with all pertinent parties achieved?”),issue likelihood 546 (e.g., highly likely), potential issues 548 (e.g.,contact attempt not made with the insured), and supervisor 550.

Upon selecting a “review and complete” selector 552, the front-enddriver engine 136 can present an alert review and complete UI screen 600as shown in FIG. 6. In some examples, the review and complete UI screen600 can display a timeline portion 602 that includes dates for differenttypes of events associated with a claim (e.g., first notice of loss,coverage analysis completed, liability analysis completed, claimantcontacted, insured liability detected). The UI screen 600, in someimplementations, can also include an alert detail section that displaysa portion of the alert information displayed in the alert section 540 atUI screen 536 (FIG. 5C). If the user viewing the alert either completesor confirms completion of a task associated with the alert (e.g.,attempting to make contact with the insured), then the user can indicatecompletion at completion selector 606. Otherwise, the user can set analert reminder 608 for the system 108 to output a reminder that the taskassociated with the alert needs to be completed. In some implementationsthe alert reminder 608 can be set for a number of hours, days, weeks, orother time period. In some examples, the alert information for detectedvulnerabilities will remain in the alerts section 540 of the UI screen536 (FIG. 5C) unless the manager 102 b selected “remind in [X] days” andthat number of days has not yet passed or the likelihood of leakage forthe detected vulnerability has been reduced (e.g., “likely” to “maybelikely” or “highly likely” to “likely”).

In some embodiments, upon selecting a “comment” selector 554 at the UIscreen 536 (FIG. 5C), the front-end driver engine 136 can present areview and comment UI screen 700 as shown in FIG. 7. In someimplementations, the review and comment UI screen 700 presents all ofthe claim notes input by the claims handler 102 a and/or manager 102 bassigned to the insurance claim. In some implementations, if the claimnotes reviewer identifies the resolution for the respective alertalready in the claim notes, the reviewer can highlight and add anassociated comment. For example, for the alert shown in the UI screen536 (FIG. 5C) about initial contact not being made, if the revieweridentifies where initial contact was notated, the reviewer can highlightthe applicable section of claim note text 702 and add a comment 704annotating what the highlight represents. In some examples, any feedbackprovided by claim alert reviewers at the UI screen 700 can be add to thedata used to train the vulnerability detection data model so that theaccuracy of the model in automatically detecting claim handling eventscan be improved.

In other examples, the UI screen 536 (FIG. 5C) also includes previousissues section that provides a log of all previously detectedvulnerabilities and any feedback, resolutions, or amplifying informationassociated with each detected vulnerability. In some implementations,once a manager 102 b has provided feedback on and/or resolved a detectedvulnerability, the front-end driver engine 136 moves the vulnerabilityand its associated feedback to the previous issues section. In someembodiments, the front-end driver engine 136 can also present a rootcause UI screen 1000 as shown in FIG. 10 that presents a list of thepossible root causes of the detected vulnerability along withcorresponding probabilities of occurrence for each of the potential rootcauses. For example, for a detected vulnerability of having missingstatements during an investigation phase, there is a 48% chance that thevulnerability is due to police officer or other official personnelstatements not being taken, a 24% chance that the vulnerability is dueto potential witness statements not being taken, and a 12% chance thatnamed insured statements were not taken.

FIGS. 11-12 show examples of statistic summary UI screens 1100, 1200that allow users to view claims handling statistics for providers 102,which allows them to see trends in how claims handlers 102 a areprogressing in various aspects of the claims handling process over time.For example, at the UI screen 1100 in FIG. 11, a user, such as a manager102 b, can view claims handling statistics 1104-1114 based on a set offiltering criteria 1102 that can include adjuster name, supervisor name,notification date, and notification month. In some examples, the claimshandling statistics 1104-1114 can include trendlines spanning a periodof months or years that show amounts of time to contact the insured 1104and claimant 1106 as well as time to liability analysis 1108 for eachclaim associated with the specified criteria 1102. The UI screen 1100,in some embodiments, can also display bar graphs showing numbers ofclaims that met predetermined time frames for accomplishing tasksassociated with claim handling (e.g., time to contact insured 1110, timeto talk to claimant 1112, time to liability analysis 1114).

Additionally, at the UI screen 1200 in FIG. 12, a user, such as amanager 102 b, can view vulnerability alert trends over time based onalert type based on a set of filtering criteria 1202 that can includeadjuster name, supervisor name, notification date, and notificationmonth. For example, at the UI screen 1200 in FIG. 12, the user can viewalert trendlines such as trendlines 1204 and 1206 that show the numberand type of alerts for a respective claims handler 102 a (adjuster). Insome examples, the trendline 1204 corresponds to a number of alertswhere an attempt at contact was made but contact with the claimant wasnot achieved, and the trendline 1206 corresponds to a number of alertswhere a contact attempt with the claimant was not made. The UI screen1200 allows managers 102 b to see the progress (or lack of progress)that a claims handler 102 a is making with respect to avoidingvulnerability alert events that can lead to claim leakage.

In addition to reviewing claim vulnerability information at a UI screenthrough a website or application, in some embodiments, users can alsoreceive claim vulnerability information in other messaging formats, suchas email or text message. For example, FIG. 8 shows UI screen 800 thatallows users to adjust email notification settings for whether theywould like to receive claim vulnerability information in a daily email,a weekly email, or no email. FIG. 9 shows an example of a daily email900 that the front-end driver engine 136 provides to a manager 102 bthat includes new or updated vulnerability data for claims under thesupervision of the manager 102 b. For example, the email 900 includes asection for claims with new vulnerabilities that have arisen within thelast day 904 and a section for claims with outstanding vulnerabilityissues 906. In some implementations, the email 900 includes weblinks foraccessing claim detail UI screens 902 (e.g., UI screens 600 and 610 inFIG. 6) upon selection of one of the claim links in the email 900.

Turning to FIG. 13A, a flow chart of an example method 1300 for traininga vulnerability detection data model is illustrated. In some examples,the method 1300 is performed by data management engine 132, claimprocessing engine 146, and analytics training engine 134 of claimsmonitoring system 108 (FIG. 1). In some embodiments, the method 1300 isperformed on a periodic basis to incorporate additional data for claimsthat have been closed since a vulnerability detection data model wastrained for a respective insurance provider 102.

In some implementations, the method 1300 commences with analyticstraining engine 134 determining whether a current trained model for arespective provider 102 is up to date (1302). In some examples, theanalytics training engine 134 determines whether the trained modelincorporates the most recent closed claims data by comparing a dateassociated with a trained vulnerability model for a provider 102 toclaim closing dates for the provider 102 stored as claim data 112 indata repository 110.

If the trained vulnerability detection data model for a provider is notup to date, then claim processing engine 146, in some implementations,extracts key vulnerability detection features from closed insuranceclaims, which is organized as client production data 129. (1304). Thevulnerability detection features, in one example, may be specific toindividual insurance providers 102 based upon a respective provider'sbusiness rules and claims handling processes.

Data management engine 132, in some embodiments, merges the clientproduction data for a provider 102 with historical data 116 to form amerged data set 118 that is used to train a vulnerability detection datamodel for the provider 102 (1306). In some examples, the data managementengine 132 normalizes the client production data 129 generated by theclaim processing engine 146 for the respective provider 102 to becompatible with the historical data 116 and merges the normalized clientproduction data 129 historical data 116 into a single merged data set118 that is customized to respective provider 102

In some implementations, analytics training engine 134 trains avulnerability detection data model for a provider 102 with the mergeddata set 118 using supervised and/or unsupervised machine learningalgorithms (1308). Because each merged data set 118 is customized to anindividual provider 102, in some examples, the analytics training engine134 can generate a trained data model that is also customized to theindividual provider 102. In some examples, the analytics training engine134 trains a vulnerability detection data model for a provider 102 withdata from the corresponding merged data set 118 for that provider 102and a targeted set of weighted training variables 124 related toproactively identifying vulnerabilities within claims that lead to claimleakage. In some examples, the training variables and weights 124 aredefault values that are manually provided to the system 108 and storedin data repository 110. In one example, the analytics training engine134 may automatically update the training weights and variables 124 asthe machine learning knowledge base grows. In some implementations, thetraining variables correspond to the claim features of the merged datasets 118 and claim features vectors 114.

In some examples, the analytics training engine 134 outputs the trainedvulnerability detection data model for the provider 102 (1310) and also,in some aspects, outputs targeted claim features for the provider 102based on the trained model (1312). For example, the analytics trainingengine 134, using the trained vulnerability detection data model, canlearn additional provider-specific vulnerability detection features overtime based on shared characteristics between claims for a provider 102.

Although illustrated in a particular series of events, in otherimplementations, the steps of the vulnerability detection data modeltraining process 1300 may be performed in a different order. Forexample, outputting a trained vulnerability detection data model (1310)may be performed before, after, or simultaneously with outputtingtargeted claim features (1312). Additionally, in other embodiments, theprocess may include more or fewer steps while remaining within the scopeand spirit of the vulnerability detection data model training process1300.

FIG. 13B is a flow chart of an example method 1320 for identifyingtarget variables for training a vulnerability detection data model. Insome implementations, the method 1320 can be performed by the analyticstraining engine 134, data management engine 132, and/or claimsprocessing engine 146. In some examples, the method 1320 can beperformed in conjunction with the claim feature extraction (1304) andmerge of claim data with historical data (1306) of the vulnerabilitydetection data model training process 1300.

In some examples, the method 1320 commences with extracting features andtarget variables from claims notes data and loss run data (1322). Thevulnerability detection features, in one example, may be specific toindividual insurance providers 102 based upon a respective provider'sbusiness rules and claims handling processes.

In some implementations, if target variables have not been identified orare missing within the extracted data (1324), then in some examples, theanalytics training engine 134 can apply one or more pattern recognitiontechniques for detecting target variables within the extracted data(1326). For example, a target variable used to train the vulnerabilitydetection data model can included whether a recorded statement from aclaimant or insured member is necessary in a particular situation. If itis not immediately evident whether a recorded statement was taken afterextracting information from the claims notes and loss run data, then insome examples, the analytics training engine 134 can use patternrecognition to detect evidence of the training variable within theextracted data. In some embodiments, the pattern recognition techniquesmay include applying a natural language classifier trained to detectidentifiers associated with target variable within unstructured claimsnotes data. In some examples, the detected target variables can belinked to the extracted features (1328), which can in some aspects beused to train the vulnerability detection data model (1330).

Although illustrated in a particular series of events, in otherimplementations, the steps of the target variable identification process1320 may be performed in a different order. For example, determiningwhether target variables are missing from extracted data (1324) may beperformed before, after, or simultaneously with linking detected targetvariables to corresponding data features (1328). Additionally, in otherembodiments, the process may include more or fewer steps while remainingwithin the scope and spirit of the target variable identificationprocess 1320.

Turning to FIG. 14, a flow chart of an example method 1400 for detectingclaim vulnerabilities is illustrated. In some examples, the method 1400is performed by data management engine 132, claim processing engine 146,and vulnerability detection engine 138 of claims monitoring system 108(FIG. 1). In some examples, the method 1400 can be performedperiodically for each open claim that is monitored by the system 108.

In some implementations, the method 1400 commences with thevulnerability detection engine 138 identifying a claim for vulnerabilitydetection (1402). In some examples, the claim data 112 for each openclaim includes a processing frequency and/or a next processing dateindicating when the claim is next due to be processed forvulnerabilities based on factors that include default processingfrequencies, predetermined claim processing milestones, and previouslydetected vulnerabilities. In some examples, a manager 102 b can manuallyinitiate vulnerability detection processing for one or more claims undersupervision of the manager 102 b.

The claim processing engine 146, in some implementations, extracts keyvulnerability detection features from stored claim data 112 for an openclaim identified for vulnerability detection processing (1404). In someexamples, the claim data 112 can include both structured andunstructured data. In one example, the structured data can include dataprovided directly to the system 108 and stored in relational databases(e.g., insurance policy information, claim identification codes, datesand times of when a claimant was contacted, official medical diagnoses).In addition, the unstructured data, in some examples, can include notesregarding any calls or interactions with a claimant, medicalprofessional, law enforcement professional, or vehicle inspector,receipts, police reports, medical records, automobile inspection reportsfor automobile insurance claims. To extract features from unstructureddata, in some implementations, the claim processing engine 146 can applya natural text detection algorithm to unstructured data files to extracttextual features.

In some embodiments, the claim processing engine 146 organizes the keyvulnerability features extracted from each open insurance claim intofeature vectors, which are stored in data repository 110 as claimfeature vectors 114 (1406). Vulnerability detection engine 138, in someembodiments, can identify vulnerabilities for a set of open claims inreal-time by applying the respective trained vulnerability detectiondata model for the provider 102 to the extracted features of the openclaim feature vectors 114 (1408). Because the analytics training engine134 generates trained data models that are customized to each provider,the vulnerability detection engine 138 can, in real-time, detectvulnerabilities related to claim leakage that are particular to anindividual provider 102. In some embodiments, based on the patterns ofclaims handling deficiencies identified by the vulnerability detectiondata model, the vulnerability detection engine 138 outputs one or morevulnerabilities detected within the claims that correspond to one ormore types of vulnerability metrics 121 associated with claim leakage.

If, in some implementations, any vulnerabilities are detected within anopen claim (1410), then in some examples, the vulnerability detectionengine 138 determines a likelihood of leakage associated with eachdetected vulnerability (1412). In one example, a likelihood of leakagefor a detected vulnerability (e.g., highly likely, likely, or maybelikely) for a claim can correspond to a confidence level for avulnerability prediction made by the trained vulnerability detectiondata model.

In some implementations, based on the detected vulnerabilities andlikelihoods of leakage occurring, claim scoring engine 142 computes avulnerability score for the claim (1414). In some implementations, thescore computed for each claim can be a function of a number ofvulnerabilities detected within each claim and a correspondinglikelihood of leakage (e.g., severity level) associated with thedetected vulnerability. In one example, the score may be an average ofthe likelihoods of leakage for the detected vulnerabilities (e.g.,critical, high, medium, and low likelihoods of claim leakage associatedwith the vulnerability). In other examples, the claim scoring engine 142may increase an overall likelihood of leakage for the claim based on atotal number of detected vulnerabilities. For example, if fivevulnerabilities with a “medium” likelihood of leakage are detected, theclaim scoring engine 142 may assign a score of “high” to the claimbecause a threshold number of detected vulnerabilities has beenexceeded. In other examples, the score for a claim corresponds to ahighest likelihood of leakage for any of the vulnerabilities detectedwithin the claim. For example, if one vulnerability is detected within aclaim with a likelihood of leakage of “high” (e.g., improper utilizationof experts/expert reports) and one vulnerability is detected with alikelihood of leakage of “low” (e.g., claim should not have beenescalated or transferred), then the claim scoring engine 142 assigns anoverall score of “high” to the claim. In other examples, the claimscoring engine calculates the claim score as a percentage or value on ascale (e.g., 0 to 10) in which lower scores indicate a lower probabilityof claim leakage based upon the number and severity of detectedvulnerabilities and higher scores indicate a higher probability of claimleakage.

In some implementations, if the likelihood of leakage associated withthe claim score is greater than a predetermined threshold (1416), thenfront-end driver engine 136 may output an automatic notification to anassigned manager 102 b for the claim via email, text message, orapplication notification (1418). In some examples, the vulnerabilitydetection engine 138 calculates a next review date for the claim basedon factors that can include the claim vulnerability score, previouslycalculated claim vulnerability scores (e.g., the claim has beenrepeatedly been scored with a high likelihood of leakage), and aprojected amount of time until a next claim milestone is reached (1420).

Although illustrated in a particular series of events, in otherimplementations, the steps of the vulnerability detection process 1400may be performed in a different order. For example, determining whetherthe score warrants notification of a manager 102 b (1416) may beperformed before, after, or simultaneously with determining a next claimreview date (1320). Further, multiple instances of the vulnerabilitydetection process 1400 can be performed simultaneously to detectvulnerabilities in multiple open claims using processing resourcesallocated to the claims monitoring system 108. Additionally, in otherembodiments, the process may include more or fewer steps while remainingwithin the scope and spirit of the vulnerability detection process 1400.

Turning to FIG. 15, a flow chart of an example method 1500 forprocessing claim vulnerability feedback to an insurance provider isillustrated. In some examples, the method 1500 is performed by usermanagement engine 130, feedback loop engine 140, and front-end driverengine 136 of claims monitoring system 108 (FIG. 1).

In some implementations, the method 1500 commences with user managementengine 130 receiving login credentials from a system user (e.g., manager102 b or claims handler 102 a) (1502). The user management engine 130,in some examples, associates a system user associated with the receivedlogin credentials with a set of assigned open and/or closed insuranceclaims. In some embodiments, front-end driver engine 136 presents claimdata for one or more of the assigned claims and/or other authorizedinformation at a remote computing device of the system user (1504). Forexample, upon receiving login credentials from a manager 102 b, thefront-end driver engine 136 can present a set of claims assigned to theclaims handlers 102 a under supervision of the manager 102 b at a UIscreen 500 (FIG. 5A) and can view further details regardingvulnerabilities associated with a claim at UI screen 536 (FIG. 5C).

In some implementations, if a system user (e.g., manager 102 b) providesfeedback for one or more detected vulnerability at a UI screen (e.g.,highlight 702 and comment field 704 in UI screen 700 in FIG. 7) (1506),the feedback loop engine 140, in some examples, updates thecorresponding claim data 112 to reflect the feedback (1508). Forexample, the feedback loop engine 140 can adjust a vulnerability scoreof an open claim based on received feedback. In some examples, thefeedback loop engine 140 can also incorporate the provided feedback intothe training data (e.g., training variables/weights 124) used to trainthe vulnerability detection data models.

In some embodiments, if the received feedback and/or claim data 112indicate that a processing frequency for the claim should be updated(1510), then in some examples, the feedback loop engine 140 determinesan updated processing frequency for the claim 1512). For example, thefeedback loop engine 140 may increase a frequency of vulnerabilitydetection processing of open claims that have been identified as havinga high risk for leakage due to previously detected vulnerabilities. Inanother example, the feedback loop engine 140 can update the next claimprocessing date to correspond to a reminder date set by a manager 102 b(see data field 608 for UI Screens 600, 610 in FIG. 6). In yet anotherexample, the feedback loop engine 140) may reduce a claim processingfrequency based on received feedback that action has already been takenfor a detected vulnerability.

Although illustrated in a particular series of events, in otherimplementations, the steps of the feedback processing process 1500 maybe performed in a different order. For example, updating claim data toinclude received feedback (1508) may be performed before, after, orsimultaneously with determining an updated processing frequency for aclaim (1512). Additionally, in other embodiments, the process mayinclude more or fewer steps while remaining within the scope and spiritof the feedback processing process 1500.

Next, a hardware description of the computing device, mobile computingdevice, or server according to exemplary embodiments is described withreference to FIG. 16. The computing device, for example, may representthe external entities 104, the insurance providers 102 (e.g., claimshandlers 102 a and managers 102 b), or one or more computing systemssupporting the functionality of the claims monitoring system 108, asillustrated in FIG. 1. In FIG. 16, the computing device, mobilecomputing device, or server includes a CPU 1600 which performs theprocesses described above. The process data and instructions may bestored in memory 1602. The processing circuitry and stored instructionsmay enable the computing device to perform, in some examples, themethods 1300, 1400, and 1500 of FIGS. 13-15. These processes andinstructions may also be stored on a storage medium disk 1604 such as ahard drive (HDD) or portable storage medium or may be stored remotely.Further, the claimed advancements are not limited by the form of thecomputer-readable media on which the instructions of the inventiveprocess are stored. For example, the instructions may be stored on CDs,DVDs, in FLASH memory, RAM, ROM, PROM, EPROM, EEPROM, hard disk or anyother information processing device with which the computing device,mobile computing device, or server communicates, such as a server orcomputer. The storage medium disk 1604, in some examples, may store thecontents of the data repository 110 of FIG. 1, as well as the datamaintained by the external entities 104 and the insurance providers 102prior to accessing by the claims monitoring system 108 and transferringto the data repository 110.

Further, a portion of the claimed advancements may be provided as autility application, background daemon, or component of an operatingsystem, or combination thereof, executing in conjunction with CPU 1600and an operating system such as Microsoft Windows 9, UNIX, Solaris,LINUX, Apple MAC-OS and other systems known to those skilled in the art.

CPU 1600 may be a Xenon or Core processor from Intel of America or anOpteron processor from AMD of America, or may be other processor typesthat would be recognized by one of ordinary skill in the art.Alternatively, the CPU 1600 may be implemented on an FPGA, ASIC, PLD orusing discrete logic circuits, as one of ordinary skill in the art wouldrecognize. Further, CPU 1600 may be implemented as multiple processorscooperatively working in parallel to perform the instructions of theinventive processes described above.

The computing device, mobile computing device, or server in FIG. 16 alsoincludes a network controller 1606, such as an Intel Ethernet PROnetwork interface card from Intel Corporation of America, forinterfacing with network 1628. As can be appreciated, the network 1628can be a public network, such as the Internet, or a private network suchas an LAN or WAN network, or any combination thereof and can alsoinclude PSTN or ISDN sub-networks. The network 1628 can also be wired,such as an Ethernet network, or can be wireless such as a cellularnetwork including EDGE, 3G, 4G, and 5G wireless cellular systems. Thewireless network can also be Wi-Fi, Bluetooth, or any other wirelessform of communication that is known. The network 1628, for example, maysupport communications between the claims monitoring system 108 and anyone of the external entities 104 and insurance providers 102.

The computing device, mobile computing device, or server furtherincludes a display controller 1608, such as a NVIDIA GeForce GTX orQuadro graphics adaptor from NVIDIA Corporation of America forinterfacing with display 1610, such as a Hewlett Packard HPL2445w LCDmonitor. A general purpose I/O interface 1612 interfaces with a keyboardand/or mouse 1614 as well as a touch screen panel 1616 on or separatefrom display 1610. General purpose I/O interface also connects to avariety of peripherals 1618 including printers and scanners, such as anOfficeJet or DeskJet from Hewlett Packard. The display controller 1608and display 1610 may enable presentation of the user interfacesillustrated, in some examples, in FIGS. 5-12.

A sound controller 1620 is also provided in the computing device, mobilecomputing device, or server, such as Sound Blaster X-Fi Titanium fromCreative, to interface with speakers/microphone 1622 thereby providingsounds and/or music.

The general purpose storage controller 1624 connects the storage mediumdisk 1604 with communication bus 1626, which may be an ISA, EISA, VESA,PCI, or similar, for interconnecting all of the components of thecomputing device, mobile computing device, or server. A description ofthe general features and functionality of the display 1610, keyboardand/or mouse 1614, as well as the display controller 1608, storagecontroller 1624, network controller 1606, sound controller 1620, andgeneral purpose I/O interface 1612 is omitted herein for brevity asthese features are known.

One or more processors can be utilized to implement various functionsand/or algorithms described herein, unless explicitly stated otherwise.Additionally, any functions and/or algorithms described herein, unlessexplicitly stated otherwise, can be performed upon one or more virtualprocessors, for example on one or more physical computing systems suchas a computer farm or a cloud drive.

Reference has been made to flowchart illustrations and block diagrams ofmethods, systems and computer program products according toimplementations of this disclosure. Aspects thereof are implemented bycomputer program instructions. These computer program instructions maybe provided to a processor of a general purpose computer, specialpurpose computer, or other programmable data processing apparatus toproduce a machine, such that the instructions, which execute via theprocessor of the computer or other programmable data processingapparatus, create means for implementing the functions/acts specified inthe flowchart and/or block diagram block or blocks.

These computer program instructions may also be stored in acomputer-readable medium that can direct a computer or otherprogrammable data processing apparatus to function in a particularmanner, such that the instructions stored in the computer-readablemedium produce an article of manufacture including instruction meanswhich implement the function/act specified in the flowchart and/or blockdiagram block or blocks.

The computer program instructions may also be loaded onto a computer orother programmable data processing apparatus to cause a series ofoperational steps to be performed on the computer or other programmableapparatus to produce a computer implemented process such that theinstructions which execute on the computer or other programmableapparatus provide processes for implementing the functions/actsspecified in the flowchart and/or block diagram block or blocks.

Moreover, the present disclosure is not limited to the specific circuitelements described herein, nor is the present disclosure limited to thespecific sizing and classification of these elements. For example, theskilled artisan will appreciate that the circuitry described herein maybe adapted based on changes on battery sizing and chemistry or based onthe requirements of the intended back-up load to be powered.

The functions and features described herein may also be executed byvarious distributed components of a system. For example, one or moreprocessors may execute these system functions, wherein the processorsare distributed across multiple components communicating in a network.The distributed components may include one or more client and servermachines, which may share processing, as shown on FIG. 17, in additionto various human interface and communication devices (e.g., displaymonitors, smart phones, tablets, personal digital assistants (PDAs)).The network may be a private network, such as a LAN or WAN, or may be apublic network, such as the Internet. Input to the system may bereceived via direct user input and received remotely either in real-timeor as a batch process. Additionally, some implementations may beperformed on modules or hardware not identical to those described.Accordingly, other implementations are within the scope that may beclaimed.

In some implementations, the described herein may interface with a cloudcomputing environment 1730, such as Google Cloud Platform™ to perform atleast portions of methods or algorithms detailed above. The processesassociated with the methods described herein can be executed on acomputation processor, such as the Google Compute Engine by data center1734. The data center 1734, for example, can also include an applicationprocessor, such as the Google App Engine, that can be used as theinterface with the systems described herein to receive data and outputcorresponding information. The cloud computing environment 1730 may alsoinclude one or more databases 1738 or other data storage, such as cloudstorage and a query database. In some implementations, the cloud storagedatabase 1738, such as the Google Cloud Storage, may store processed andunprocessed data supplied by systems described herein. For example, theclaim data 112, claim feature vectors 114, historical data 116, mergeddata sets 118, vulnerability data 120 vulnerability metrics 121, traineddata models 122, trained variables/weights 124, feedback data 126,handler performance data 127, claim scoring data 128, and clientproduction data 129 may be maintained by the claims monitoring system108 of FIG. 1 in a database structure such as the databases 1738.

The systems described herein may communicate with the cloud computingenvironment 1730 through a secure gateway 1732. In some implementations,the secure gateway 1732 includes a database querying interface, such asthe Google BigQuery platform. The data querying interface, for example,may support access by the claims monitoring system 108 to data stored onany one of the external entities 104 and insurance providers 102.

The cloud computing environment 1730 may include a provisioning tool1740 for resource management. The provisioning tool 1740 may beconnected to the computing devices of a data center 1734 to facilitatethe provision of computing resources of the data center 1734. Theprovisioning tool 1740 may receive a request for a computing resourcevia the secure gateway 1732 or a cloud controller 1736. The provisioningtool 1740 may facilitate a connection to a particular computing deviceof the data center 1734.

A network 1702 represents one or more networks, such as the Internet,connecting the cloud environment 1730 to a number of client devices suchas, in some examples, a cellular telephone 1710, a tablet computer 1712,a mobile computing device 1714, and a desktop computing device 1716. Thenetwork 1702 can also communicate via wireless networks using a varietyof mobile network services 1720 such as Wi-Fi, Bluetooth, cellularnetworks including EDGE, 3G, 4G, and 5G wireless cellular systems, orany other wireless form of communication that is known. In someexamples, the wireless network services 1720 may include centralprocessors 1722, servers 1724, and databases 1726. In some embodiments,the network 1702 is agnostic to local interfaces and networks associatedwith the client devices to allow for integration of the local interfacesand networks configured to perform the processes described herein.Additionally, external devices such as the cellular telephone 1710,tablet computer 1712, and mobile computing device 1714 may communicatewith the mobile network services 1720 via a base station 1756, accesspoint 1754, and/or satellite 1752.

While certain embodiments have been described, these embodiments havebeen presented by way of example only and are not intended to limit thescope of the present disclosures. Indeed, the novel methods, apparatusesand systems described herein can be embodied in a variety of otherforms; furthermore, various omissions, substitutions and changes in theform of the methods, apparatuses and systems described herein can bemade without departing from the spirit of the present disclosures. Theaccompanying claims and their equivalents are intended to cover suchforms or modifications as would fall within the scope and spirit of thepresent disclosures.

What is claimed is:
 1. A system comprising: processing circuitry; anon-transitory database storage region configured to store a pluralityof vulnerability detection data models each associated with a particularinsurance provider of a plurality of insurance providers, wherein eachof the plurality of vulnerability detection data models is trained witha feature vector of claim metrics from a plurality of insurance claimsassociated with the particular insurance provider of the plurality ofinsurance providers; and a non-transitory computer readable memorycoupled to the processing circuitry, wherein the memory is configured tostore machine-executable instructions, and wherein themachine-executable instructions, when executed by the processingcircuitry, cause the processing circuitry to: identify, based on apredetermined claim monitoring frequency, at least one insurance claimof a plurality of insurance claims identified for vulnerabilitydetection processing, wherein each identified claim is associated withthe particular insurance provider of the plurality of insuranceproviders, and for each of the at least one identified insurance claims:extract, from data files associated with a respective identifiedinsurance claim, vulnerability detection features for the respectiveidentified insurance claim, wherein the extracted vulnerabilitydetection features provide an indication of claim handling deficienciesthat have a likelihood of resulting in claim leakage, detect, using arespective trained vulnerability detection data model of the pluralityof trained vulnerability detection data models associated with theparticular insurance provider, one or more claim handlingvulnerabilities within the extracted vulnerability detection features ofthe respective identified insurance claim, wherein each of the detectedone or more claim handling vulnerabilities includes a likelihood of therespective detected claim handling vulnerability resulting in claimleakage, calculate a respective vulnerability score for the respectiveidentified insurance claim indicating an overall likelihood of claimleakage based on the detected one or more claim handlingvulnerabilities, determine, based in part on the calculated respectivevulnerability score, a respective priority level associated with thedetected one or more claim handling vulnerabilities, and transmit,automatically and in real-time, responsive to determining that therespective priority level exceeds a predetermined threshold, anotification alert to a remote computing device of a respective claimhandling supervisor, wherein the notification alert indicates that thepriority level for the respective identified insurance claim exceeds thepredetermined threshold.
 2. The system of claim 1, wherein the datafiles associated with each of the at least one identified insuranceclaims include structured and unstructured data files.
 3. The system ofclaim 2, wherein the unstructured data files include at least one ofnotes regarding any calls or interactions with one or more parties tothe at least one identified insurance claim, receipts, police reports,medical records, or automobile inspection reports.
 4. The system ofclaim 2, wherein extracting the vulnerability detection features for therespective identified insurance claim comprises applying a naturallanguage processing algorithm trained to detect claim vulnerabilityfeatures within the unstructured data files.
 5. The system of claim 1,wherein the data files associated with each of the at least oneidentified insurance claims include data files from open and closedclaims associated with the particular insurance provider.
 6. The systemof claim 5, wherein the machine-executable instructions, when executedby the processing circuitry, cause the processing circuitry to:generate, from the data files associated with the particular insuranceprovider, the feature vector of claim metrics for the particularinsurance provider, wherein the feature vector of claim metrics includesentries representing characteristics of the open and closed claims. 7.The system of claim 6, wherein the entries of the feature vector ofclaim metrics include labeled data extracted from the open and closedclaims for the particular insurance provider.
 8. The system of claim 7,wherein the machine-executable instructions, when executed by theprocessing circuitry, cause the processing circuitry to: identify, fromthe entries of the feature vector of claim metrics, one or more targetvariables corresponding to a detectable vulnerability within therespective identified insurance claim.
 9. The system of claim 8, whereinthe machine-executable instructions, when executed by the processingcircuitry, cause the processing circuitry to: determine, from theentries of the feature vector of claim metrics, that one or more of theclaim metrics associated with a portion of the one or more targetvariables are missing from the entries of the feature vector of claimmetrics, identify, based on application of a pattern recognitionalgorithm to unlabeled data in the open and closed claims for theparticular insurance provider, one or more additional claim metricsassociated with the portion of the one or more target variables, andlink the identified one or more additional claim metrics to the featurevector of claim metrics used to train the respective vulnerabilitydetection data model.
 10. The system of claim 1, wherein each of theclaim metrics is associated with one of a plurality of claim metriccategories, the claim metric categories including two or more of claimassignment metrics, contact metrics, coverage metrics, investigationmetrics, evaluation metrics, or litigation management metrics.
 11. Thesystem of claim 10, wherein the contact metrics category includes atleast one of an initial contact attempt, an initial contact date, orsubsequent contact dates with one or more parties to the respectiveidentified insurance claim.
 12. The system of claim 1, wherein detectingthe one or more claim handling vulnerabilities includes determining thatone or more of the claim metrics are not met for the respectiveidentified insurance claim.
 13. The system of claim 1, wherein themachine-executable instructions, when executed by the processingcircuitry, cause the processing circuitry to: adjust, based on a numberand a type of the detected one or more claim handling vulnerabilities, arespective predetermined claim monitoring frequency for the respectiveidentified insurance claim.
 14. The system of claim 1, wherein themachine-executable instructions, when executed by the processingcircuitry, cause the processing circuitry to: detect, within theplurality of insurance claims, that one or more documents have beenadded to a first insurance claim of the plurality of insurance claims,and initiate, responsive to detecting the one or more added documents,processing of the first insurance claim for detected vulnerabilities.15. The system of claim 1, wherein a portion of the plurality ofinsurance claims are automobile insurance claims.
 16. A methodcomprising: training, by processing circuitry of a computing device, aplurality of vulnerability detection data models each associated with aparticular insurance provider of a plurality of insurance providers todetect indications of claim handling deficiencies in claims associatedwith the particular insurance provider that have a likelihood ofresulting in claim leakage, wherein each of the plurality ofvulnerability detection data models is trained with a feature vector ofclaim metrics from a plurality of insurance claims associated with theparticular insurance provider of the plurality of insurance providers,and wherein the plurality of trained vulnerability detection models aresaved in a data storage region; identifying, based on a predeterminedclaim monitoring frequency, at least one insurance claim of a pluralityof insurance claims identified for vulnerability detection processing,wherein each identified claim is associated with the particularinsurance provider of the plurality of insurance providers; and for eachof the at least one identified insurance claims: extracting, by theprocessing circuitry from data files associated with a respectiveidentified insurance claim, vulnerability detection features for therespective identified insurance claim, wherein the extractedvulnerability detection features provide an indication of claim handlingdeficiencies that have a likelihood of resulting in claim leakage,detecting, by the processing circuitry using a respective trainedvulnerability detection data model of the plurality of trainedvulnerability detection data models associated with the particularinsurance provider stored in the data storage region, one or more claimhandling Vulnerabilities within the extracted vulnerability detectionfeatures of the respective identified insurance claim, wherein each ofthe detected one or more claim handling vulnerabilities includes alikelihood of the respective detected one or more claim handlingvulnerabilities resulting in claim leakage, calculating, by theprocessing circuitry, a respective vulnerability score for therespective identified insurance claim indicating an overall likelihoodof claim leakage based on the detected one or more claim handlingvulnerabilities, determining, by the processing circuitry based in parton the calculated respective vulnerability score, a respective prioritylevel associated with the detected one or more claim handlingvulnerabilities, and transmitting, automatically and in real-time,responsive to determining that the respective priority level exceeds apredetermined threshold, a notification alert to a remote computingdevice of a respective claim handling supervisor, wherein thenotification alert indicates that the priority level for the respectiveidentified insurance claim exceeds the predetermined threshold.
 17. Themethod of claim 16, wherein the data files associated with each of theat least one identified insurance claims include structured andunstructured data files.
 18. The method of claim 17, wherein extractingthe vulnerability detection features for the respective identifiedinsurance claim comprises applying a natural language processingalgorithm trained to detect claim vulnerability features within theunstructured data files.
 19. The method of claim 16, wherein the datafiles associated with each of the at least one identified insuranceclaims include data files from open and closed claims associated withthe particular insurance provider.
 20. The method of claim 19, furthercomprising: generating, from the data files associated with theparticular insurance provider, the feature vector of claim metrics forthe particular insurance provider, wherein the feature vector of claimmetrics includes entries representing characteristics of the open andclosed claims.